Icd 10 Guidelines Study Guide

The rules of coding are represented in the Official __________ for Coding and Reporting/

Inpatient guidelines

If there is no clear cut outpatient guideline to follow, which type of guideline would you refer to?

True

It is important to code all the conditions that are being managed during an encounter.

Etiology

The cause of disease or condition is also known as its _________.

First-listed

When two or more interrelated conditions exist, either could be the __________ diagnosis.

Z codes

Which codes are used when a person who is not ill receives health care services?

21

How many chapters are located in Volume 1, Tabular list of ICD-10-CM?

Signs and symptoms

When a specific diagnosis is not yet known what do you report?

uncertain diagnosis

In an outpatient setting, _________ _________ are not reported.

Primary

Which term is now used in place of principle diagnosis?

Outpatient

The majority of the services that a physician will provide are _________ services.

Uniform Hospital Discharge Data Set

UHDDS

UHDDS

definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals.

First-listed diagnosis

In the outpatient setting, the term _________ ________ is used in lieu of principal diagnosis.

chief complaint

Most physicians will document the _______ ________ of the patient for each encounter in the medical record. The _______ ________ is the reason the patient presents for the medical visit. The ______ ________ is one of the keys to determining the first-listed diagnosis. The ________ _________ is the reason for the visit from the patient’s perspective.

Z23

Code _______ is for encounters for inoculations and vaccinations; may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.

False

When a patient is to have outpatient surgery and the surgery is not performed due to contraindication, the reason that the surgery was not performed is the first listed diagnosis.

True

It is appropriate to code postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery.

True

Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions.

True

In the physician office it is acceptable to report Z codes as a first-listed diagnosis.

False

In the outpatient setting it is unacceptable to have a sign or symptom as the first-listed diagnosis.

False

When coding an encounter for preoperative evaluation, the reason that the patient is having the surgery or procedure performed is the first-listed diagnosis.

True

In the outpatient setting, diagnoses that are documented as “probable”, “suspected”, “rule out”, or “questionable” are reported to the highest degree of certainty.

False

The first-listed diagnosis is defined as the diagnosis that is the most serious.

False

It is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80.

False

It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.

False

Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services take precedence over the general and disease specific guidelines.

True

Always begin the search for the correct code assignment in the Alphabetic Index.

False

When a patient presents for outpatient surgery and the surgery is canceled, report the reason why the surgery was canceled as the first-listed diagnosis.

False

The codes from A00 through Z99 are always reported as first-listed diagnoses.

True

When a final diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms.

False

External Cause codes are located in the Alphabetical Index for Diseases under External Causes.

False

Report all conditions that coexist, even if they are not addressed or do not affect management/treatment during that encounter.

True

For patients receiving diagnostic services only during an encounter/visit, sequence first the reason for the encounter/visit indicated in the medical record.

False

A patient with primary lung cancer with metastasis to the spine presents for radiation treatment of the spine. The first-listed diagnosis reported is the primary lung cancer.

False

For patients receiving preoperative evaluations, sequence first a code from the subcategory Z01.81, Encounter for preprocedural examinations, followed by findings related to the preoperative evaluation.

True

Routine prenatal outpatient visits for high-risk patients are reported with a first-listed diagnosis from category O09, Supervision of high-risk pregnancy.

True

Z codes may be reported as a principal diagnosis in the hospital setting.

True

Heart transplant status code Z94.1 should not be reported with a code from subcategory T86.2, Complications of heart transplant.

False

The External Cause codes can be reported as a first-listed diagnosis.

False

When a patient is admitted to observation for a complication following outpatient surgery, report the complication as the first-listed diagnosis.